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All inquiries for research and information about thyroid cancer and thyroid disease in Orthopaedic Surgeons, doctors and or nurses, can be directed to Dr Peter Dewey, Research Co-ordinator, Australian Orthopaedic Association, PO Box 12, Arncliffe NSW 2205, Australia.

Managed Care an Update

On a recent visit to the USA I had a chance to speak to American Orthopaedic Surgeons about Managed Care. The bad news has gotten worse. Consider the following:

As the insurance company not the patient is responsible for paying the doctors account many doctors have to gain approval prior to seeing a patient … this may involve your secretary spending 20 minutes on the phone to an insurance provider. Multiply this by the number of patients you see in a day and this will tie your staff in knots for hours.

A colleague of mine working for Kaiser Permanente (an HMO) was unhappy that a foot x-ray took 45 minutes to do. He voiced his concerns to the practice manager and was told that he was an “employee just like the radiographer and that he had no right to criticise her”. He resigned shortly afterwards.

Corporate America is brokering healthcare without a stroke of government intervention, Health insurance company executives are being paid bonuses by the tens of millions of dollars. This money is obtained by restricting services to the patient and by cutting fees to their doctors.

Litigation against Managed care plans is on the increase as patients are being denied treatment.

Many employers change plans for their employees each year. The untenable situation arises when a postop patient is no longer covered by their plan or when a patient with a chronic disease can no longer see their treating doctor.

We don’t want America’s gun laws and we don’t want their health system. If you are offered a Managed care contract “Whatever you do, just don’t sign.”

Dr John P Negrine
National Secretary
Australian Society of Orthopaedic Surgeons
(March 1997)

“Rushing to introduce radical changes to the health workforce based on the recent Productivity Commission Research Report may backfire”, Dr Don Sheldon, Chairman, Council of Procedural Specialists (COPS) said today. COPS released a 10 point public statement in response to the report.

Many aspects of the report need to be considered carefully including the admission by the Commission that it was unable to fully assess health sector productivity and efficiency, “overall, currently available information does not support the full assessment of health sector productivity and hence the efficiency of health service provision” (p 381).

While pushing the case for task substitution the Commission then qualifies itself with calls for a detailed “case by case assessment” and the establishment of an agency “to assess the contribution that such changes could make” (p 58) This is clear evidence that the Commission is uncertain and not convinced of the outcome of its own recommendations.

Chairman of the Australian Society of Orthopaedic Surgeons, Dr Gary Speck said in Melbourne, “that there is a big difference between delegation and substitution”. Task substitution means standing on your own two feet and taking total responsibility including legal liability for what you do. Delegation involves submitting to the authority of someone more competent than you. “Our members will not be placed in a situation where they are liable for the actions of others over whom they have no control”, Dr Speck said.

Dr Don Sheldon said the Commission had also acknowledged that it was not able to look into matters of health policy and health funding that have a significant impact on the productivity of doctors particularly in the public hospital sector. “This is a major frustration for doctors who are unable to fully utilise their skills in our public hospital system due to cuts in operating theatre time and lack of beds at critical times. Task substitution will not fix this”.

Dr Sheldon said claims of a future shortage of doctors had to be re-considered against the Commission’s finding that “on a doctor to population basis Australia is not markedly behind in regard to practising medical practitioners” and that “Australia’s (paid) health workforce has been growing considerably faster than the population “and that medical school and specialist training enrolments were running at record levels and that workforce forecasting is “fraught with danger”.

The existing arrangements of training and regulation have delivered what the Commission concedes is a great result. “Australians have among the highest life expectancies in the world – including when disability adjusted for years of good health. Yet total of health care spending as % of GDP is not overly high by advanced OECD standards”.

Dr Sheldon said, “Doctors value the work and contributions to patient care given by nurses and allied health professionals but are part of a separate profession which must remain separate in its teaching, practice and regulation to ensure best patient care and outcome. Whilst there are lesser standards elsewhere Australians should have the best.”

COPS acknowledges the PCRR’s observations (pg 1) that “Australians have among the highest life expectancies in the world – including when disability adjusted for years of good health. Yet total of health care spending as % of GDP is not overly high by advanced OECD standards”.

COPS agrees with the PCRR (pg 1) that, “These outcomes are due in no small measure to the expertise and commitment of Australia’s health workforce and that of various professional and representative bodies in the health, education and training sectors which contribute both directly and indirectly to the delivery of health services”

COPS regrets the admission by the PCRR (pg 387) that it was unable to fully assess health sector productivity and efficiency, “overall, currently available information does not support the full assessment of health sector productivity and hence the efficiency of health service provision.”

COPS commends the report (pg xv1) for identifying that there are also some 200,000 administrative and service workers employed in the health services.. COPS believes this explains to some degree observations of its members of a growing bureaucracy at every level of the health workforce.

COPS regrets that the PCRR (pg 15) was unable in its terms of reference to examine the productivity issues flowing from health policy and health funding. Hence public hospital funding arrangements were not part of the report despite this being an area that clinicians believe directly inhibits their productivity and is responsible for under-utilisation of skilled medical practitioners including proceduralists.

COPS acknowledges the PCRR admission (pg 339) that, “In comparison to most other OECD countries, Australia does not appear to be significantly undersupplied with health workers. For example, on a doctor to population basis, Australia is not markedly behind in regard to practising medical practitioners – though the distribution of these practitioners between general practice and other specialties is different” and that (pg 334) “Australia’s (paid) health workforce has been growing considerably faster than the population (11% nearly double the population growth of around 6%). Medical professionals 12.6% (1996-2001), registered nurses and midwifes 7.3% (1997 – 2003). Furthermore (p.338) medical school commencements of Australian citizens and permanent residents increased by 90% or 800 places (1995-2004), specialists in training similarly increased by around 700 (2000-2003), a rise of 14%.

COPS is pleased that the Commission has acknowledged (pg 10) the speculative nature of all workforce forecasts and the perils of basing decisions on same. “Of course attempting to predict the future is fraught with danger while broad trends can be identified, the ways in which these trends will interact and play out are often unclear” furthermore on (pg 11) Identifying ‘shortages’ in workforce supply is not straightforward, especially given the difficulty of establishing underlying health care demand and an appropriate level of workforce response, and the extensive involvement of governments in delivering or otherwise influencing the level of resources provided to meet that demand.

COPS acknowledges the admission by the PCRR (pg xv) that it does not have expertise in matters of clinical judgement “moreover the Commission does not profess expertise in relation to specific workplace requirements, matters of clinical judgement or particular approaches to health workforce education and training.” Furthermore the PCRR acknowledges (p. 58) “enhancing the ability of nurses to substitute for doctors in some roles could exacerbate an existing nurse shortage”.

COPS believe the Commission’s endorsement of task substitution is surprising given its admission (point 3) that it was unable to fully assess health sector productivity and efficiency. Furthermore, the motives of those vigorously advocating this approach remain untested and uncertain. COPS has publicly expressed its concern at any attempt to lower the standards of anaesthesia by substituting nurse practitioners for medically trained anaesthetists. These standards have been achieved by dedication and skill. The Commission should not assume that these standards would be maintained despite major alterations to the safeguards patients presently enjoy. The Medical profession has a long and deserved history as leader in the teaching and practice of all branches of the medical care of patients. Doctors value the work and contributions to patient care given by nurses and allied health professionals but are part of a separate profession which must remain separate in its teaching, practice and regulation to ensure best patient care and outcome. Whilst there are lesser standards elsewhere Australians are entitled to the best.

COPS believes that many of the proposals of the PCRR are simply rearranging the bureaucracy and advocating special interest changes without the assurance of significant productivity improvements.